Solvating system and sealant for medical use in the sinuses and nasal passages

ABSTRACT

Chronic rhinosinusitis and other bacterial sinus conditions may be treated by applying a solvating system containing a surfactant to a bacterial biofilm in a nasal or sinus cavity, disrupting the biofilm, and applying a protective layer of a polymeric film-forming medical sealant.

CROSS REFERENCE TO RELATED APPLICATION

This application is a continuation-in-part of copending U.S. patentapplication Ser. No. 11/431,495 filed May 10, 2006, the entiredisclosure of which is incorporated herein by reference.

FIELD OF THE INVENTION

This invention relates to the treatment of chronic rhinosinusitis andother bacterial sinus conditions.

BACKGROUND

Chronic rhinosinusitis (CRS) is inflammation of the paranasal sinusesand is associated with anterior or posterior nasal discharge, nasalobstruction or facial pressure, pain or fullness lasting for at leastabout twelve weeks. CRS affects an estimated 10% or more of the U.S.population. Most patients with CRS are initially treated with medicaltherapy, but hundreds of thousands undergo functional endoscopic sinussurgery (FESS) for refractory CRS every year. Patients with CRS oftenhave a reduced quality of life, and may require billions of dollars inannual health-care and lost work time costs. CRS is a Th1 and Th2inflammatory response to a number of mechanisms including but notlimited to bacterial toxins, extracellular polysaccharide matricessecreted by bacteria and contained within a bacterial biofilm, fungi,developed allergic reactions to both bacteria and fungi (IgE) and autoimmune disorders. Bacteria associated with CRS and its accompanyinginflammation include Staphylococcus aureus, Pseudomonas aeruginosa,Streptococcus pneumonia, Haemophilus influenzae and Moraxellacatarrhalis. Biofilms containing one or more of these species andpossibly also containing fungi may be a factor in the pathogenesis ofCRS, see e.g., Ramadan et al., “Chronic rhinosinusitis and biofilms”,Otolaryngol Head Neck Surg. 132:414-417 (2005) and Ferguson et al.,“Demonstration of Biofilm in Human Bacterial Chronic Rhinosinusitis”, AmJ Rhinol, 5:19, pp. 452-57 (2005). Biofilms form when bacteria interactwith a surface to form polymeric films (sometimes referred to asexopolysaccharide or extracellular polysaccharide polymers) that coatthe surface and provide a living colony for further bacterialproliferation. Bacteria lodged in biofilms are much more difficult toremove or kill than bacteria in a plaktonic (suspended) state, and areextremely resistant to many antibiotics and biocides. The extracellularpolysaccharide (EPS) matrix, the toxins produced by the bacterialcolony, and the fungi that the bacterial biofilm may harbor may each becapable of inciting an inflammatory response from the host.

SUMMARY OF THE INVENTION

Although antibiotics may initially be administered at elevated dosagesto address CRS, they are generally ineffective as they cannot penetratethe bacterial cell walls through the EPS and cannot interrupt celldivision as bacteria at the core of a bacterial biofilm are sessile andnot dividing. Additionally, antibiotic administration can promote drugresistance in the targeted and other bacterial species. It would behighly desirable to employ alternative treatments that permit areduction or elimination in the amount of required antibiotics yetdiscourage recurrence of the treated condition. When the treatedcondition involves a bacterial biofilm on a tissue surface, it would bedesirable to remove or disrupt the biofilm so that remaining bacteriamay more effectively be attacked by antibiotics or by the body's ownnatural defenses. It would also be desirable to at least temporarilyseal or otherwise protect the thus-treated surface in order to repelbacterial adherence and biofilm reformation. It would also be desirableto do so while meeting biocompatibility requirements for contact withhuman tissue, and while using small dosages of administered materialsand short periods of application.

The present invention provides in one aspect a method for treatingrhinosinusitis and other bacterial sinus conditions, which methodcomprises:

-   -   a) applying a solvating system comprising a surfactant to a        treatment site comprising a bacterial biofilm attached or        adhered to a surface within a nasal or sinus cavity,    -   b) detaching, removing or otherwise disrupting at least a part        of the biofilm, and    -   c) applying to the treatment site a protective layer of a        polymeric film-forming medical sealant.

The invention provides in another aspect a composition for discouragingbacterial recolonization and biofilm reformation on tissue from which abiofilm has been removed, the composition comprising a polymericfilm-forming medical sealant and an antimicrobial agent comprising agallium-containing compound.

The disclosed method may be used for rhinological treatment orpost-operative care, and may be used to treat maladies or chronicconditions including chronic rhinosinusitis and other bacterial sinusconditions.

BRIEF DESCRIPTION OF THE DRAWING

FIG. 1 is a schematic view showing the disclosed method;

FIG. 2 is a perspective view of a surgical biofilm removal instrumentwhich may be used in the disclosed method.

Like reference symbols in the various figures of the drawing indicatelike elements. The elements in the drawing are not to scale.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

The following detailed description describes certain embodiments and isnot to be taken in a limiting sense. All weights, amounts and ratiosherein are by weight, unless otherwise specifically noted. The termsshown below have the following meanings:

The term “antimicrobial agent” refers to a substance having the abilityto cause greater than a 90% numeric reduction (viz., at least a 1-logorder reduction) in a population of one or more of Staphylococcusaureus, Pseudomonas aeruginosa, S. pneumonia, Haemophilus influenzae orMoraxella catarrhalis or any other bacteria implicated in the etiologyof chronic rhinosinusitis using the bacterial plate count proceduredescribed below in the Examples.

The terms “attached” and “adhered” when used in reference to a bacterialbiofilm and a surface mean that the biofilm is established on and atleast partially coats or covers the surface, and has some resistance toremoval from the surface. As the nature of this relationship is complexand poorly understood, no particular mechanism of attachment oradherence is intended by such usage.

The term “adhesion” refers to the sticking together of a material totissues or tissue to tissue with which it is in intimate contact forextended periods or tissue that connects opposing tissues or prostheticmaterials across a normally open space.

The term “bacterial biofilm” means a community of bacteria attached to asurface, with the organisms in the community being contained within anEPS matrix produced by the bacteria.

The term “biocompatible” when used in reference to a substance meansthat the substance presents no significant deleterious or untowardeffects upon the body.

The term “biodegradable” when used in reference to a substance meansthat the substance will degrade or erode in vivo to form smallerchemical species. Such degradation process may be enzymatic, chemical orphysical.

The term “bioresorbable” when used in reference to a substance meansthat the substance is capable of being absorbed by the body.

The terms “detaching”, “removing” and “disrupting” when used inreference to a bacterial biofilm attached or adhered to a surface meanthat at least a significant amount of the biofilm initially present onthe surface no longer is attached or adhered to the surface. Noparticular mechanism of detachment, removal or disruption is intended bysuch usage.

The term “hemostat” means a device or material which stops blood flow.

The term “nasal or sinus cavities” refers to the various tissuesdefining the normally air-filled passages and chambers within the noseand sinus including but not limited to the nostrils or nares, the nasalconcha or turbinates, the frontal, ethmoid, sphenoid and maxillarysinuses, the sinus ostia and the nasopharnyx, and to objects or articles(e.g., prostheses, packing or stents) that may be placed within a nasalor sinus cavity.

The term “polymeric sealant” means that the sealant is either formedfrom a synthetic crosslinked or uncrosslinked polymer or is a naturalmaterial such as a protein which has been crosslinked (e.g.,synthetically crosslinked).

The term “residence time” when used in reference to a polymeric sealantat a treatment site means the time period during which the sealantremains in place in vivo under gross observation.

The term “sequestering agent” means a chemical that will combine withanother material, especially a metal ion, to discourage or prevent thematerial from coming out of solution. The term “metal ion sequesteringagent” means a sequestering agent that will combine with one or moremetal ions such as alkali metals, alkaline earth metals, iron and thelike to discourage or prevent the metal ion from coming out of solution.In order of increasing atomic number the alkali metals are lithium,sodium, potassium, rubidium, cesium, and francium, and the alkalineearth metals are beryllium, magnesium, calcium, strontium, barium, andradium.

The term “solvating” means to form a solution or dispersion containing asolvent or other carrier within which a solute is dissolved orsuspended.

Referring to FIG. 1, the disclosed method may be performed in the nasalor sinus cavities 100 of a patient, including the maxillary sinuses 110a, 110 b and frontal sinuses 112 a, 112 b, which may be accessed throughnares 114 a, 114 b. It should be noted that external features of thepatient, including nares 114 a, 114 b, are shown in dashed lines. Whenthe patient suffers for example from chronic rhinosinusitis, one or moretreatment sites such as treatment site 116 associated with a surface ofmaxillary sinus 110 a may be surgically addressed to substantiallyremove part or all of the biofilm at the treatment site and prevent ordiscourage bacterial recolonization. Treatment site 116 includesciliated epithelium of maxillary sinus 110 a and an associated layer ofbacteria inhabiting an associated biofilm (not shown in FIG. 1). Thetreatment site need not be natural tissue and may instead be anartificial structure (not shown in FIG. 1) such as a sinus packing orstent covered at least in part with a layer of bacterial biofilm. Thedisclosed solvating system may be applied treatment site 116 using anintroducer 120 with an articulatable nozzle 122 containing an irrigationduct (hidden in FIG. 1) through which the solvating system may flow tothe distal end of introducer and thence to the treatment site. Thesolvating system and residues of the biofilm may be removed from thetreatment site via an aspiration duct (hidden in FIG. 1). The disclosedpolymeric film-forming medial sealant may likewise be applied at thetreatment site using the same or a different irrigation duct inintroducer 120. Those skilled in the art will appreciate that thesolvating system, sealant or both solvating system and sealant may beapplied to the treatment site using other methods or devices. Exemplaryother methods include trephination and exemplary other devices includesyringes (e.g., glass syringes and bulb syringes).

FIG. 2 shows an exemplary biofilm removal surgical instrument 200 whichmay be used in the disclosed method. Instrument 200 includes a handle202, an introducer 222, a nozzle 224 (referenced generally) andirrigation and aspiration ducts (not shown in FIG. 2). Instrument 200can optionally further include a first actuator assembly 226 (referencedgenerally) and a second actuator assembly 228 (referenced generally). Acontrol wheel 230 in first actuator assembly 226 may be operable by auser to effectuate bending of the introducer 222, and a control wheel232 in second actuator assembly 228 may be operable by a user toeffectuate movement or rotation of nozzle 224 relative to introducer222. The handle 202 serves generally as a housing for various othercomponents of instrument 200 and retains introducer 222. Handle 202 mayhave a pistol grip-like shape, defining a grip portion 234 and a nose236. The grip portion 234 is sized and shaped for grasping by a user'shand, whereas the nose 236 is adapted for connection to the introducer222. Trigger 238 and an associated sensor and valve (not shown in FIG.2) may be used to control the flow of the disclosed solvating systemthrough irrigation tubing 240 and thence to the distal end of introducer222 through nozzle 224 and onto the desired treatment site. Trigger 238may be provided with a multidirectional range of motion and associatedwith one or more additional sensors and valves (not shown in FIG. 2) tocontrol removal of the solvating system, biofilm residue and otherdebris from the treatment site through nozzle 224 and thence toaspiration tubing 242. Trigger 238 may also be used to control the flowof the disclosed sealant through a separate lumen in irrigation tubing240 and thence to the distal end of introducer 222 through nozzle 224and onto the desired treatment site.

The solvating system may be applied to the desired treatment site todetach, remove or otherwise disrupt at least a part of a bacterialbiofilm attached or adhered to at least a portion of the nasal or sinuscavities. The solvating system desirably is applied in at least anamount and thickness sufficient to cover the desired portion of thebiofilm. The treatment may involve chemical dilution or mechanicaldisruption. For example, the solvating system may be applied as apressurized spray to dislodge the bacterial biofilm, bacteria and otherforeign body buildup at the treatment site. Application of the solvatingsystem or other liquids (e.g., saline solution) may be performed usingpressure, spray patterns, motion or other techniques to accomplishhydrodebridement at the treatment site. While not wishing to be bound bytheory, the solvating system may dissolve the biofilm and bring it intosolution or suspension so that the thus-disrupted biofilm can be easilyflushed or otherwise removed from the treatment site using aspiration,lavage or other removal techniques. Any remaining bacteria at thetreatment site may then more readily be attacked by an antimicrobialagent or by the body's natural defenses. Bacterial attack may forexample be assisted by including an antimicrobial agent in the solvatingsystem or in the polymeric film-forming medical sealant, or byseparately applying an antimicrobial agent intra operatively or postoperatively (e.g., topically, orally or systemically). It may bedesirable to inject sufficient solvating system into the treatment areato displace any pus or other material that may be present, allowingexcess material to overflow from the treatment area until the color ofthe excess material no longer changes. The solvating system may be leftin place until it can drain away or is otherwise eliminated or resorbed,or the solvating system may be allowed to stand for a suitable time(e.g., a few minutes, a few hours or longer) and then may be rinsed awayusing saline or another suitable liquid. Application of the solvatingsystem and removal of dislodged or disrupted biofilm and bacteria mayalso be repeated as desired to ensure thorough removal of the offendingorganisms.

To discourage bacterial recolonization and biofilm reformation, thepolymeric film-forming medical sealant is also applied to the treatmentsite. This may for example be accomplished using an introducer 120 or222 as shown in FIG. 1 and FIG. 2 to dispense the film-forming medicalsealant onto the treatment site. The applied sealant may fill thetreated nasal or sinus cavities or may be applied as a film or otherconformal coating that leaves at least a partial air opening in thetreated cavities. The sealant desirably adheres to natural tissues atthe treatment site and resists detachment or other disruption untilnatural degradation or resorption of the sealant takes place (e.g.,after a residence time of one or more days or weeks). Meanwhilerecolonization or reinfection may be significantly reduced or prevented,and improved healing and reciliation may take place. The sealant mayprovide various therapeutic advantages including but not limited tobacterial adhesion repellence, anti-infective properties, local immunemodulation, tissue protection, reduction or elimination of pain orbleeding, reduction in inflammation, optimization of environment forciliary regrowth, reduction in adhesions to critical anatomy, or thelike. These advantages may arise due to a variety of mechanismsincluding a) inhibiting bacterial colonization, b) inhibiting theadherence of bacteria to tissue, c) reducing tissue morbidity or abscessformation, d) reducing or preventing disease recurrence (for example,specifically reducing the chronic inflammation related to bacterialtoxin and EPS), e) coating and protecting tissue during healing, such asby maintenance of a moist wound which promotes platelet aggregation, orby closure of a dry wound without excessive scabrous formation, f)hemostasis, g) optimizing the environment for reciliation of the mucosa,h) speeding the growth or regrowth of cilia and i) deliveringtherapeutic agent(s) to the treatment site. Desirably the sealant willattach to a portion of the mucosa, cover other portions of the mucosawhile leaving the cilia in such unattached portions free to undergonatural rhythmic cilia motion (viz., cilia beating), deliverantimicrobial agents or additional therapeutic agents as needed, andprevent bacteria from adhering to the treatment site.

A variety of solvating systems may be used in the disclosed method. Asnoted above, the solvating system comprises surfactant. The surfactantdesirably is water-soluble and nontoxic. Exemplary surfactants includeanionic surfactants, nonionic surfactants, cationic surfactants andzwitterionic surfactants. Exemplary anionic surfactants include but arenot limited to C₆-C₂₄ alkylbenzene sulfonates; C₆-C₂₄ olefin sulfonates;C₆-C₂₄ paraffin sulfonates; cumene sulfonate; xylene sulfonate; C₆-C₂₄alkyl naphthalene sulfonates; C₆-C₂₄ alkyl or dialkyl diphenyl ethersulfonates or disulfonates, C₄-C₂₄ mono or dialkyl sulfosuccinates;sulfonated or sulfated fatty acids; C₆-C₂₄ alcohol sulfates (for exampleC₆-C₁₂ alcohol sulfates); C₆-C₂₄ alcohol ether sulfates having 1 toabout 20 ethylene oxide groups; C₄-C₂₄ alkyl, aryl or alkaryl phosphateesters or their alkoxylated analogues having 1 to about 40 ethylene,propylene or butylene oxide units; and mixtures thereof. For example,the anionic surfactant may be sodium chenodeoxycholate,N-lauroylsarcosine sodium salt, lithium dodecyl sulfate,1-octanesulfonic acid sodium salt, sodium cholate hydrate, sodiumdeoxycholate, sodium dodecyl sulfate (also known as sodium laurylsulfate) or sodium glycodeoxycholate.

Exemplary cationic surfactants include but are not limited to quaternaryamine compounds having the formula:

where R, R′, R″ and R″′ are each a C₁-C₂₄ alkyl, aryl or aralkyl groupthat can optionally contain one or more P, O, S or N heteroatoms, and Xis F, Cl, Br, I or an alkyl sulfate. For example, the cationicsurfactant may be hexadecylpyridinium chloride monohydrate orhexadecyltrimethylammonium bromide.

Exemplary nonionic surfactants include but are not limited to C₆-C₂₄alcohol ethoxylates (for example C₆-C₁₄ alcohol ethoxylates) having 1 toabout 20 ethylene oxide groups (for example about 9 to about 20 ethyleneoxide groups); C₆-C₂₄ alkylphenol ethoxylates (for example C₈-C₁₀alkylphenol ethoxylates) having 1 to about 100 ethylene oxide groups(for example about 12 to about 20 ethylene oxide groups); C₆-C₂₄alkylpolyglycosides (for example C₆-C₂₀ alkylpolyglycosides) having 1 toabout 20 glycoside groups (for example about 9 to about 20 glycosidegroups); C₆-C₂₄ fatty acid ester ethoxylates, propoxylates orglycerides; C4-C₂₄ mono or di alkanolamides; and mixtures thereof. Forexample, the nonionic surfactant may be polyoxyethyleneglycol dodecylether, N-decanoyl-N-methylglucamine, digitonin, n-dodecyl B-D-maltoside,octyl B-D-glucopyranoside, octylphenol ethoxylate, polyoxyethylene (8)isooctyl phenyl ether, polyoxyethylene sorbitan monolaurate orpolyoxyethylene (20) sorbitan monooleate.

Exemplary zwitterionic surfactants include but are not limited toaminoalkylsulfonate compounds having the formula:

where R, R′, R″ and R″′ are each a C₁-C₂₄ alkyl, aryl or aralkyl groupthat can optionally contain one or more P, O, S or N heteroatoms; amineoxide compounds having the formula:

where R, R′and R″ are each a C₁-C₂₄ alkyl, aryl or aralkyl group thatcan optionally contain one or more P, O, S or N heteroatoms; and betainecompounds having the formula:

where R, R′and R″ are each a C₁-C₂₄ alkyl, aryl or aralkyl group thatcan optionally contain one or more P, O, S or N heteroatoms, and n isabout 1 to about 10. For example, the zwitterionic surfactant may be3-[(3-cholamidopropyl)dimethylammonio]-2-hydroxy-1-propane sulfonate,3-[(3-cholamidopropyl)dimethylammonio]-1-propane sulfonate (sometimesreferred to as CHAPS), 3-(decyldimethylammonio)propanesulfonate innersalt (sometimes referred to as caprylyl sulfobetaine), orN-dodecyl-N,N-dimethyl-3-ammonio-1-propanesulfonate.

Preferred surfactants include alkyl sulfates, alkyl sulfonates, arylsulfonates and zwitterionic surfactants. The desired surfactants may beobtained as pure compounds or in some instances may be obtained by usingproducts such as liquid Castile soap. The surfactant may for example bepresent at a concentration of at least about 0.002 M, at least about0.005 M or at least about 0.01 M, e.g., about 0.002 to about 1 M, about0.005 to about 0.7 M or about 0.01 to about 0.5 M. Expressed on a weightbasis, the surfactant may for example be greater than about 0.2 wt. % ofthe solvating system, e.g., about 0.3% to about 30%, about 0.5% to about25% or about 1% to about 20% of the solvating system. Increasedsurfactant amounts may promote faster biofilm breakup.

The solvating system may optionally contain a metal ion sequesteringagent. The sequestering agent desirably is a mild acid whose acidity issufficient to sequester one or more metal ions in the exopolysaccharideor extracellular polysaccharide matrix, but which is not so acidic so asto harm the treated nasal or sinus cavity tissue. Metal ions ofparticular interest (due to their likely involvement in the targetedbacterial biofilms) include sodium, calcium and iron. The metal ionsequestering agent desirably is water-soluble and nontoxic.Representative acids include but are not limited to carboxylic acids,diacids, or triacids such as formic acid, acetic acid, chloroaceticacid, dichloroacetic acid, oxalic acid, oxamic acid, glycolic acid,lactic acid, pyruvic acid, aspartic acid, fumaric acid, maleic acid,succinic acid, iminodiacetic acid, glutaric acid, 2-ketoglutaric acid,glutamic acid, adipic acid, citric acid, glucuronic acid, mucic acid,nitrilotriacetic acid, salicylic acid, ketopimelic acid, benzoic acid,mandelic acid, chloromandelic acid, phenylacetic acid, phthalic acid andboric acid; mineral acids such as hydrochloric acid, orthophosphoricacid and phosphonic acid; and mixtures thereof. Citric acid is apreferred acid. The metal ion sequestering agent may for example bepresent at a concentration of at least about 0.01 M, at least about 0.05M or at least about 0.1 M, e.g., about 0.01 to about 0.5 M, about 0.05to about 0.4 M or about 0.1 to about 0.3 M. Increased metal ionsequestering agent amounts may promote faster biofilm breakup.

The solvating system may optionally include a variety of otheringredients, including water and other solvents (e.g., alcohols),buffering agents, antimicrobial agents and a variety of adjuvants.Preferably the solvating system contains water and one or more bufferingagents. The buffering agent preferably maintains the solvating system atan appropriate pH for contacting human tissue, and desirably at a pHgreater than 5. For example, the solvating system may be buffered tohave a near-neutral pH, e.g., a pH greater than 5 and less than 8.5.Buffering agents may for example be up to about 25% of the solvatingsystem. Exemplary buffering agents include but are not limited topotassium chloride, glycine, potassium hydrogen phthalate, sodiumacetate, potassium hydrogen phthalate, barbitone sodium and sodiumcitrate. When the metal ion sequestering agent is a mild acid, thebuffering agent desirably is a salt of that acid.

Solvating systems containing one or more antimicrobial agents are alsopreferred. The EPS matrix allows the biofilm to stick to an underlyingsurface and also protects the embedded organisms; thus, bacteria inbiofilms are approximately 100 to 1000 times more resistant to theeffects of antibiotics than planktonic bacteria. After the biofilm hasbeen broken down into unbound polymers or fragments and solvated orotherwise disrupted by the solvating system, an antimicrobial agent canmuch more effectively attack the remaining bacteria. Exemplaryantimicrobial agents include active oxygen compounds such as hydrogenperoxide, isolated or equilibrium derived or isolated peracids such aschloroperbenzoic acids, peracetic acid, perheptanoic acid, peroctanoicacid, perdecanoic acid, performic acid, percitric acid, perglycolicacid, perlactic acid, perbenzoic acid, and monoester peracids derivedfrom diacids or diesters such as adipic, succinic, glutaric, or malonicacid; amphenicols; ampicillins; ansamycins; beta-lactams such ascarbacephems, carbapenems, cephalosporins, cephamycins, monobactams,oxacephems, penicillins and any of their derivatives; carboxylic esterssuch as p-hydroxy alkyl benzoates and alkyl cinnamates; chitosan salts;cubic-phase lipids; gallium-containing antimicrobial agents such asgallium acetylacetonate, gallium bromide, gallium chloride, galliumfluoride, gallium iodide, gallium maltolate, gallium nitrate, galliumnitride, gallium percolate, gallium phosphide and gallium sulfate;iodo-compounds and other active halogen compounds such as iodine,interhalides, polyhalides, metal hypochlorites, hypochlorous acid, metalhypobromites, hypobromous acid, chloro- and bromo-hydantoins, chlorinedioxide and sodium chlorite; lincosamides; macrolides; nitrofurans;organic peroxides including benzoyl peroxide and alkyl benzoylperoxides; ozone; phenolic derivatives including o-phenyl phenol,o-benzyl-p-chlorophenol, tert-amyl phenol and C₁-C₆ alkyl hydroxybenzoates; quaternary ammonium compounds such as alkyldimethylbenzylammonium chloride and dialkyldimethyl ammonium chloride; quinolines;singlet oxygen generators; sulfonamides; sulfones; sulfonic acids suchas dodecylbenzene sulfonic acid; tetracyclines; vancomycin; derivativesthereof and mixtures thereof. Many of these recited agents representclasses containing useful specific materials whose individual utilitywill be recognized by persons having ordinary skill in the art. Forexample, exemplary penicillins include but are not limited toamdinocillin, amdinocillin pivoxil, amoxicillin ampicillin, apalcillin,aspoxicillin, axidocillin, azlocillin, acampicillin, bacampicillin,benzylpenicillinic acid, benzylpenicillin sodium, carbenicillin,carindacillin, clometocillin, cloxacillin, cyclacillin, dicloxacillin,epicillin, fenbenicillin, floxacillin, hetacillin, lenampicillin,metampicillin, methicillin sodium, mezlocillin, nafcillin sodium,oxacillin, penamecillin, penethamate hydriodide, penicillin Gbenethamine, penicillin G benzathine, penicillin G benzhydrylamine,penicillin G calcium, penicillin G hydrabamine, penicillin G potassium,penicillin G. procaine, penicillin N, penicillin O, penicillin V,penicillin V banzathine, penicillin V hydrabamine, penimepicycline,phenethicillin potassium, piperacillin, pivampicillin propicillin,quinacillin, sulbenicillin, sultamicillin, talampicillin, temocillin,ticarcillin and mixtures thereof or with other materials (e.g.,penicillins combined with clavulanic aid such as the combination ofamoxicillin and clavulanic acid available as AUGMENTIN™ fromGlaxoSmithKline).

An antimicrobial agent such as those described above may optionally beapplied in a separate treatment step (if need be in a suitable carrier)after application of the solvating system and before application of thepolymeric film-forming medical sealant. An antimicrobial agent may alsobe applied as a part of the sealant. Whether applied as a part of thesolvating system, in a separate step, or as a part of the sealant, theantimicrobial agent preferably provides greater than a 99% numericreduction (viz., at least a 2-log order reduction), greater than a 99.9%numeric reduction (viz., at least a 3-log order reduction), greater thana 99.99% numeric reduction (viz., at least a 4-log order reduction) orgreater than a 99.999% numeric reduction (viz., at least a 5-log orderreduction) in a population of one or more of S. aureus, P. aeruginosa,S. pneumonia, H. influenzae or M. catarrhalis bacteria using thebacterial plate count procedure described below in the Examples.

The solvating system may contain additional therapeutic agents.Exemplary therapeutic agents include any material suitable forrhinologic use including analgesics, anti-cholinergics, anti-fungalagents, antihistamines, steroidal or non-steroidal anti-inflammatoryagents, anti-parasitic agents, antiviral agents, biostatic compositions,chemotherapeutic/antineoplastic agents, cytokines, decongestants,immunosuppressors, mucolytics, nucleic acids, peptides, proteins,steroids, vasoconstrictors, vitamins, mixtures thereof, and othertherapeutic materials that will be apparent to those skilled in the art.Several such additional therapeutic agents are discussed in more detailbelow in connection with the polymeric film-forming medical sealant.Other adjuvants that may be included in the solvating system includedyes, pigments or other colorants (e.g., FD & C Red No. 3, FD & C RedNo. 20, FD & C Yellow No. 6, FD & C Blue No. 2, D & C Green No. 5, D & COrange No. 4, D & C Red No. 8, caramel, titanium dioxide, fruit orvegetable colorants such as beet powder or beta-carotene, turmeric,paprika and other materials that will be familiar to those skilled inthe art); indicators; flavoring or sweetening agents including but notlimited to anise oil, cherry, cinnamon oil, citrus oil (e.g., lemon,lime or orange oil), cocoa, eucalyptus, herbal aromatics (e.g., cloveoil, sage oil or cassia oil), lactose, maltose, menthol, peppermint oil,saccharine, sodium cyclamate, spearmint oil, sorbitol, sucrose,vanillin, wintergreen oil, xylitol and mixtures thereof; antioxidants;antifoam agents; and rheology modifiers including thickeners andthixotropes.

The solvating system desirably has a sufficiently low viscosity toenable easy delivery to the treatment site using for example power sprayor other spray application, lavage, misting, mopping, wicking ordripping. The solvating system desirably also may be easily removed fromthe treatment site by subsequent flushing, rinsing, draining orabsorption. The solvating system need not be applied in liquid form andmay for example be applied as a powder, gel, foam, sponge, film strip orother suitable form. The solvating system desirably does not containingredients which might potentially harm tissues or structures in thenasal or sinus cavities.

A variety of polymeric film-forming medical sealants may be used in thedisclosed method. The sealant preferably is a biodegradable orbioresorbable material having a residence time in vivo of from one dayto a few (e.g., 2, 3 or 4) days, weeks or months. The sealant may beuncrosslinked, crosslinked before being applied to the treatment site,or crosslinked after application. In one embodiment, the sealant may bea viscoelastic material. In another embodiment, the sealant may hardenafter application. The sealant may be a synthetic polymer (for example,polyethylene glycol or PEG), natural polymer (for example, apolysaccharide, lipid or polypeptide), or a synthetically-modifiednatural polymer (for example, a polypeptide reacted with PEG). Otherexemplary synthetic polymers include polyacetals, polyacrylic acid,polyalkylene oxalates, polyalkylene succinates, polyamides, polyaminoacids, polyaspartic acid, polyanhydrides, polycaprolactones,polycarbonates, polycyanoacrylates, polydiaxonones, polyesteramides,polyetheresters, polyethylene oxide (PEO), poly(glycolic acids) andother poly(glycolides), polyhydroxybutyrates, polyhydroxyvalerates,polyketals, poly(lactic acid) and other polylactides includingpoly(lactide-co-glycolides), poly(malic acids), polyorthoesters,polyphosphazines, polyphosphoesters, polypropylene oxide (PPO),degradable polyurethanes, polyvinyl alcohol (PVA), polyvinyl pyrrolidone(PVP), and copolymers, terpolymers, blends, and mixtures thereof.

Exemplary polysaccharides include cellulose and its derivatives such asoxidized cellulose, hydroxyethyl cellulose, carboxymethyl cellulose(CMC), carboxymethyl amylose (CMA), carboxyethyl cellulose andhydroxypropylmethyl cellulose (HPMC); chitin; chitosan and itsderivatives such as carboxymethyl chitosan and trimethylchitosan;dextran and its derivatives such as carboxymethyl dextran; glycogen;glycosaminoglycans such as hyaluronan (e.g., hyaluronic acid and itsderivatives including esters and polymers), heparin, heparin sulfate,dermatin sulfate, and chondroitin-6-sulfate; gums such as alginate,gellan gum and xanthan gum; pectin; and starch and its derivatives.

Exemplary lipids include glyceryl based lipid compounds such as glycerylmonooleate, and liquid crystal lipids which can be delivered in fluidform and which when in contact with moisture will convert to a cubicphase to provide a waxy cubic or crystalline material.

Exemplary polypeptides include albumin, collagen, gelatin, silk andtheir derivatives. For example, crosslinked hydrogels may be formed frommany polypeptides by reacting them with a suitable crosslinking agentsuch as an aldehyde (e.g., glutaraldehyde or formaldehyde),carbodiimide, chitin, CMC or a glycol such as a PEG.

The polymeric film-forming medical sealant may include antimicrobialagents, additional therapeutic agents and other adjuvants like thosementioned above in connection with the solvating system. Sealantscontaining therapeutic agents that offer both anti-infective andanti-inflammatory properties (e.g., tetracyclines) are a preferredembodiment. Sealants containing additional therapeutic agents such asanti-fungal agents, antihistamines, steroidal or non-steroidalanti-inflammatory agents, anti-parasitic agents, antiviral agents,chemotherapeutic/antineoplastic agents, decongestants or mucolytics areanother preferred embodiment. Sealants containing antimicrobial agentsand additional therapeutic agents are yet another preferred embodiment.Exemplary anti-fungal agents include but are not limited to allylamines,imidazoles, polyenes, thiocarbamates, triazoles, derivatives thereof andmixtures thereof. Exemplary antihistamines include but are not limitedto azelastine, diphenhydramine, loratidine, derivatives thereof andmixtures thereof. Exemplary steroidal anti-inflammatory agents includebut are not limited to 21-acetoxypregnenolone, alclometasone, algestone,amcinonide, beclomethasone, betamethasone, budesonide, chloroprednisone,clobetasol, clobetansone, clocortolone, cloprednol, corticosterone,cortisone, cortivazol, deflazacort, desonide, desoximetasone,dexamethasone, diflorasone, diflucortolone, difluprednate, enoxolone,fluazacort, flucloronide, flumethasone flunisolide, fluocinoloneacetonide, fluocinonide, fluocortin butyl, fluocortolone,fluorometholone, fluperolone acetate, fluprednidene acetate,fluprednisolone, flurandrenolide, fluticasone propionate, formocortal,halcinonide, halobetasol propionate, halometasone, halopredone acetate,hydrocortamate, hydrocortisone, loteprednol etabonate, mazipredone,medrysone, meprednisone, methylprednisolone, mometasone furoate,paramethosone, prednicarbate, prednisolone, prednisolone25-diethylamino-acetate, prednisolone sodium phosphate, prednisone,prednival, prednylidene, rimexolone, tixocortol, triamcinolone,triamcinolone acetonide, triamcinolone benetonide, triamcinolonehexacetonide, derivatives thereof and mixtures thereof. Preferredsteroidal anti-inflammatory agents include beclomethasone, budesonide,fluticasone proprionate and mometasonefuroate. Exemplary nonsteroidalanti-inflammatory agents include but are not limited to COX inhibitors(COX-1 or COX nonspecific inhibitors) and selective COX-2 inhibitors.Exemplary COX inhibitors include but are not limited to salicylic acidderivatives such as aspirin, sodium salicylate, choline magnesiumtrisalicylate, salicylate, diflunisal, sulfasalazine and olsalazine;para-aminophenol derivatives such as acetaminophen; indole and indeneacetic acids such as indomethacin and sulindac; heteroaryl acetic acidssuch as tolmetin, dicofenac and ketorolac; arylpropionic acids such asibuprofen, naproxen, flurbiprofen, ketoprofen, fenoprofen and oxaprozin;anthranilic acids (fenamates) such as mefenamic acid and meloxicam;enolic acids such as the oxicams (piroxicam, meloxicam); alkanones suchas nabumetone; derivatives thereof and mixtures thereof. Exemplary COX-2inhibitors include but are not limited to diaryl-substituted furanonessuch as refecoxib; diaryl-substituted pyrazoles such as celecoxib;indole acetic acids such as etodolac and sulfonanilides such asnimesulide; derivatives thereof and mixtures thereof. Exemplaryanti-parasitic agents include but are not limited to atovaquoneclindamycin, dapsone, iodoquinol, metronidazle, pentamidine, primaquine,pyrimethamine, sulfadiazine, trimethoprim/sufamethoxazole, trimetrexate,derivatives thereof and mixtures thereof. Exemplary antiviral agentsinclude but are not limited to acyclovir, famciclovir, valacyclovir,edoxudine, ganciclovir, foscamet, cidovir (available as VISTIDE™ fromGilead Sciences, Inc.), vitrasert, formivirsen, HPMPA(9-(3-hydroxy-2-phosphonomethoxypropyl)adenine), PMEA(9-(2-phosphonomethoxyethyl)adenine), HPMPG(9-(3-hydroxy-2-(phosphonomethoxy)propyl)guanine), PMEG(9-[2-(phosphonomethoxy)ethyl]guanine), HPMPC(1-(2-phosphonomethoxy-3-hydroxypropyl)-cytosine), ribavirin, EICAR(5-ethynl-1-beta-D-ribofuranosylimidazole-4-carbonxamine), pyrazofurin(3-[beta-D-ribofuranosyl]-4-hydroxypyrazole-5-carboxamine),3-Deazaguanine, GR-92938X(1-beta-D-ribofuranosylpyrazole-3,4-dicarboxamide), LY253963(1,3,4-thiadiazol-2-yl-cyanamide), RD3-0028(1,4-dihydro-2,3-benzodithiin), CL387626(4,4′-bis[4,6-di][3-aminophenyl-N,N-bis(2-carbamoylethyl)-sulfonilimino]-1,3,5-triazine-2-ylamino-biphenyl-2-,2′-disulfonicacid disodium salt), BABIM (bis[5-amidino-2-benzimidazoly-1]-methane),NIH351, derivatives thereof and mixtures thereof. Exemplarychemotherapeutic/antineoplastic agents include but are not limited toantitumor agents (e.g., cancer chemotherapeutic agents, biologicalresponse modifiers, vascularization inhibitors, hormone receptor blocks,and cryotherapeutic agents or other agents that destroy or inhibitneoplasia or tumorigenesis) such as alkylating agents or other agentswhich directly kill cancer cells by attacking their DNA (e.g.,cyclophosphamide and isophosphamide), nitrosoureas or other agents whichkill cancer cells by inhibiting changes necessary for cellular DNArepair (e.g., carmustine (BCNU) and lomustine (CCNU)), antimetabolitesand other agents that block cancer cell growth by interfering withcertain cell functions, usually DNA synthesis (e.g., 6 mercaptopurineand 5-fluorouracil (5FU)), antitumor antibiotics and other compoundsthat act by binding or intercalating DNA and preventing RNA synthesis(e.g., doxorubicin, daunorubicin, epirubicin, idarubicin, mitomycin-Cand bleomycin), plant (vinca) alkaloids and other anti-tumor agentsderived from plants (e.g., vincristine and vinblastine), steroidhormones, hormone inhibitors, hormone receptor antagonists and otheragents which affect the growth of hormone-responsive cancers (e.g.,tamoxifen, herceptin, aromatase inhibitors such as aminoglutethamide andformestane, triazole inhibitors such as letrozole and anastrazole, andsteroidal inhibitors such as exemastane), antiangiogenic proteins, smallmolecules, gene therapies or other agents that inhibit angiogenesis orvascularization of tumors (e.g., meth-1, meth-2 and thalidomide),bevacizumab (available as AVASTIN™ from Genentech), squalamine,endostatin, angiostatin, ANGIOZYME™ from Ribozyme Pharmaceuticals,neovastat (available as AE-941™ from Aeterna Zentaris), CC-5013(available as REVIMID™ from Celgene Corp.), medi-522 (available asVITAXIN™ from MedImmune, Inc.), 2-methoxyestradiol or 2ME2 (available asPANZEM™ from Entremed, Inc.), carboxyamidotriazole (CAI), combretastatinA4 prodrug (CA4P), SU6668, SU11248, BMS-275291, COL-3, EMD 121974,IMC-1C11, IM862, TNP-470, celecoxib (available as CELEBREX™ from PfizerInc.), refecoxib, interferon alpha, interleukin-12 (IL-12) or any of thecompounds identified in Science Vol. 289, Pages 1197-1201 (Aug. 17,2000) which is expressly incorporated herein by reference, biologicalresponse modifiers (e.g., interferon, bacillus calmette-guerin (BCG),monoclonal antibodies, interluken 2, granulocyte colony stimulatingfactor (GCSF), etc.), PGDF receptor antagonists, herceptin,asparaginase, busulphan, carboplatin, cisplatin, carmustine,chlorambucil, cytarabine, dacarbazine, etoposide, flucarbazine,flurouracil, gemcitabine, hydroxyurea, ifosphamide, irinotecan,lomustine, melphalan, mercaptopurine, methotrexate, thioguanine,thiotepa, tomudex, topotecan, treosulfan, vinblastine, vincristine,mitoazitrone, oxaliplatin, procarbazine streptocin, taxol or paclitaxel,taxotere, analogs/congeners, derivatives thereof and mixtures thereof.Exemplary decongestants include but are not limited to epinephrine,oxymetazoline, phenylephrine, pseudoephedrine, tetrahydrozolidine,xylometazoline, derivatives thereof and mixtures thereof. Exemplarymucolytics include but are not limited to acetylcysteine, dornase alpha,guaifenesin, derivatives thereof and mixtures thereof.

In those instances where it is desirable to remove water from tissue,e.g., to remove fluid from polyps or edematous tissue, a hyperosmolaragent may be employed in the sealant. Exemplary hyperosmolar agentsinclude but are not limited to furosemide, sodium chloride gel and othersalt preparations that draw water from tissue or substances thatdirectly or indirectly change the osmolar content of the mucous layer.Where sustained release or delayed release of the therapeutic agent isdesirable, a release agent modifier may also be included in the sealant.

The sealant desirably has a sufficiently low viscosity to enable easydelivery to the treatment site using for example power spray or otherspray application, lavage, misting, mopping, wicking or dripping. Thesealant need not be applied in liquid form and may for example beapplied as a powder, gel, foam, sponge, film strip or other suitableform. The applied sealant may be bioresorbable or biodegradable after adesired period of time once healing has occurred. The sealant desirablyincludes at least one characteristic that promotes retention of thesealant at the treatment site. This characteristic may be selected froma variety of features including but not limited to thickness, size,shape, density, viscosity, hardness, bioadhesiveness, mucoadhesiveness,manner of application or insertion, and the like. The sealant mayprevent bacterial recolonization or the formation or reformation ofbacterial biofilms by covering the treatment site (e.g., mucosa fromwhich a bacterial biofilm has been removed by the solvating system) withan alternative film structure whose surface is not readily penetrable bybacteria associated with bacterial sinus conditions. The sealantdesirably does not contain ingredients which might potentially harmtissues or structures in the nasal or sinus cavities.

The solvating system and sealant may desirably be used as a part of amulti-step treatment regimen which disrupts the bacterial biofilm anddiscourages its return. For example, a series of steps that may bebroadly classified as Cleansing/Disrupting, Killing, Protecting/Coating,Aerating, and Healing may be carried out. The Cleansing/Disrupting stepmay be carried out by administering the solvating system as describedabove. The Killing step may be carried out by applying a suitableantimicrobial agent to the treatment site. This may as described abovebe accomplished by including an antimicrobial agent in the solvatingsystem, in the sealant, or in both the solvating system and sealant. Asnoted above, an antimicrobial agent may also be applied as a separatestep between application of the solvating system and application of thesealant. An antimicrobial agent may also be applied or administered postoperatively. The Protecting/Coating step may be carried out by coatingat least part of the thus-treated tissue with a protective sealant layeras described above. The Aerating step may be carried out by providingair passageways or improving air passageways to the treated tissues byopening occluded or partially occluded nasal passages, sinuses or sinusostia. This may for example be accomplished by surgically removingobstructive tissue structures or by manually displacing such structures.The Healing step may be carried out by allowing the cleansed, protectedand sealed tissue surface to undergo a return to a normal state, e.g.,through one or more healing mechanisms such as modulation of aninflammatory response, phagocytosis, mucosal remodeling, reciliation orfull or partial restoration of normal sinus function. The disclosedmethod may advantageously be accomplished without requiring surgery, forexample by applying and removing the solvating system and by applyingthe sealant through normal aspiration/suction techniques or by simpleflushing of affected nasal passages without infusing the solvatingsystem or sealing into the more difficult to reach sinuses beyond thesinus ostia.

A comparable series of steps may be performed in a multi-step treatmentregimen which disrupts a bacterial biofilm in a portion of the middle orinner ear. Further details regarding such a regimen may be found incopending application Serial No. (attorney docket no. 151-P-28168US01),filed even date herewith, the entire disclosure of which is incorporatedherein by reference.

The invention is further illustrated in the following non-limitingexamples.

EXAMPLE 1

Bacterial isolates of S. aureus and P. aeruginosa were recovered fromthe sinuses of patients with sinus disorders. Patients with cysticfibrosis or an underlying immunosuppressive disease (HIV infection,insulin-dependent diabetes mellitus, or renal disease) and patients whohad taken antibiotics or oral prednisone in the previous month wereexcluded. All patients had refractory sinusitis, that is, persistentsymptoms resistant to medical therapy despite having undergonetechnically successful functional endoscopic sinus surgery (FESS) forrefractory chronic rhinosinusitis (CRS) with or without nasal polyposis.The occurrence of CRS was diagnosed in accordance with the 2003 AmericanAcademy of Otolaryngology—Head and Neck Surgery (AAO-HNS) guidelines setout in Benninger et al., “Adult chronic rhinosinusitis: Definitions,diagnosis, epidemiology, and pathophysiology”, Otolaryngol Head NeckSurg 129 (3 suppl):S1-S32 (2003). The selected patients had beenrefractory to medical therapy for more than 12 months before samplecollection, and the failure of FESS was judged not to be associated withtechnical factors such as obstructive synechiae, frontal sinusobstruction, or a retained uncinate process. Samples were collectedconsecutively until 10 specimens each of S. aureus and P. aeruginosawere obtained using direct endoscopic guidance and the proceduredescribed by Nadel et al., “Endoscopically guided cultures in chronicsinusitis”, Am J Rhinol 12:233-241 (1998). Briefly, a topical anestheticagent was administered, the nasal ala retracted, and an endoscope usedto visualize the middle meatus and sinus cavities. A thin, flexiblecalcium alginate swab (STARSWAB II™ Collection and Transport System,Starplex Scientific, Etobicoke, Ontario) was inserted and directed tothe site with the most purulence. If no purulence was observed, thesurface of the maxillary sinus was swabbed for 15 seconds. Care wastaken to avoid contact with the lateral nasal wall or nasal vestibule.Samples were plated and incubated using standard procedures. Bacteriawere identified using a VITEK 2™ system (Biomérieux, Durham, N.C.).Crystal violet staining to confirm the presence of biofilms wasperformed according to the method described by Stepanovic et al., “Amodified microtiter-plate test for quantification of staphylococcalbiofilm formation”, J Microbiol Methods 40:175-179 (2000). Forincubation and culture, previously frozen strains were inoculated ontrypticase soy agar (TSA) with 0.5% sheep blood. After 24 hours, one tofour colonies per strain were cultured on TSA. Cultures were incubatedat 37° C. for 24 hours to condition them to a trypticase soy broth(TSB)-TSA medium and ensure noncontamination. Colonies grown on TSAsolid medium were then amplified in 5 mL of TSB medium with 0.5% glucoseaccording to the method described by Gotz, “Staphylococcus andbiofilms”, Mol Microbiol 43:1367-1378 (2002) and incubated at 37° C. forat least 24 hours.

A drip-flow reactor (DFR) was used to determine the effectiveness ofvarious test solutions delivered to S aureus and P aeruginosa biofilmson hydroxyapatite (HA)-coated microscope slides for removing thesebacterial biofilms with and without hydrodynamic force. The slides inthe DFR are tipped at 10° from the horizontal, thereby modeling a lowshear environment. The DFR was housed in an incubator at 37° C. underaerobic conditions. Approximately 20 minutes before bacterialinoculation, sterile medium (10% TSB for S aureus; 1% TSB for Paeruginosa) was dripped on the slides in the DFR and allowed to collectover the slides to form a conditioning layer. The slides were theninoculated with 1 mL of a culture of either S aureus or P aeruginosa.The DFR was tilted so that the slides would be horizontal for 4 hours toallow bacterial attachment to the substrate. Subsequently, the DFR wasset so that the slides were once again at a 10° angle, with sterilemedium dripping on the slides at a rate of 10 mL per hour. After 3 days,biofilm-removal experiments were performed. Two methods were used totreat the biofilms formed by each bacterial species. The firstapplication method involved a static treatment in the DFR, with asolvating agent (referred to as CAZS) being dripped onto the biofilms.The CAZS solvating agent contained deionized water, 25 g/L(corresponding to 0.13 M) citric acid, 5.35 g/L (corresponding to 0.02M) caprylyl sulfobetaine zwitterionic surfactant(CH₃(CH₂)₉N⁺(CH₃)₂CH₂CH₂CH₂SO₃ ⁻, CAS 15163-36-7) and sufficient sodiumcitrate (about 240 g/L) to buffer the system to pH 5.4. The secondapplication method involved delivery of saline or delivery of CAZSoutside the DFR, using a pressurized jet lavage to apply a hydrodynamicshearing force to the biofilm. For all treatments, preliminary runs weredone to ensure that variations among slides were within acceptablelimits. In addition, multiple plates of both bacterial species wereproduced to determine the within-run and run-to-run variations. Acontrol slide was made for each DFR run. Three runs were evaluated foreach treatment of each type of bacteria.

For static treatment, flow to the DFR was halted, the DFR was placed ina horizontal position, and the cover was removed. A 25 mL portion ofCAZS was applied to one slide. Control slides were not treated withCAZS. After 10 minutes, the slides were rinsed with saline (25 mL). TheDFR was then disconnected from the inflow tube, and each slide wasremoved under a laminar flow hood and placed in a sterile 50-mL tube.After another saline rinse (2 mL), the surface of the slide was scrapedrepeatedly, and the scrapings and saline were collected in the tube. Thetube was vortexed for 10 seconds, sonicated for 2 minutes, and vortexedagain for 10 seconds to disperse the bacteria into suspension. Thesuspensions were then serially diluted and 100-μL aliquots applied tothree plates containing TSA and incubated at 37° C. for 24 hours.Colony-forming units (CFUs) were counted manually, and the number ofCFUs per square centimeter was calculated. The resulting plate countswere log (10) transformed and expressed as the mean (±SD) value derivedfrom plate counts from two DFR runs of three slides each.

For hydrodynamic treatment, the slides were removed from the DFR andplaced in a glove box. The slides were placed in a holder and sprayedfor approximately 20 seconds with about 150 mL of either saline or CAZSusing a device that provided pressurized jet lavage. The spraying wasdone with both a side-to-side and an up-and-down sweeping motion so thatall areas were sprayed twice, once in each axis. The slides were thenplaced in sterile 50-mL tubes, rinsed, scraped, dispersed, incubated andevaluated as described above.

The mean (±SD) percent reduction from control values in the quantity ofS. aureus and P. aeruginosa bacteria (viz., the number of CFUs on eachplate) after each treatment was calculated and the results assessedusing two-sample t tests (MINITAB™ version 14, Minitab, State College,Pa.). A P value less than 0.05 was considered to represent a significantdifference from the control value. The results are shown below in Table1, expressed as the mean (±SD) number of colony-forming units percentimeter (log) derived from three plates assessed twice:

TABLE 1 Bacterial Plate Log Counts According to Type of TreatmentTreatment Staphylococcus aureus Pseudomonas aeruginosa None (Control)8.7 ± 0.4 9.2 ± 0.2 Static CAZS delivery 6.2 ± 0.3 6.3 ± 1.3Hydrodynamic saline 6.4 ± 0.2 6.9 ± 0.1 delivery Hydrodynamic CAZS 4.8 ±0.3 4.0 ± 0.5 delivery

The results in Table 1 show that significant bacterial biofilm removalwas obtained. Before treatment, ample biofilms formed in the DFRcultures of both S. aureus and P. aeruginosa, with CFU counts for theseControls ranging from 7.8 to 9.5 log/cm². Static administration of CAZSresulted in a 2.5 log reduction (5.11×10⁸ to 1.65×10⁶; P=0.001) in thenumber of S. aureus CFUs and a 2.9 log reduction (1.69×10⁹ to 1.91×10⁶;P=0.002) in the number of P. aeruginosa CFUs. Mechanical disruptionusing hydrodynamic saline delivery alone decreased the number of S.aureus CFUs by 2.3 log units (5.11×10⁸ to 2.38×10⁶; P=0.001) and thenumber of P. aeruginosa CFUs by 2.4 log units (1.69×10⁹ to 7.31×10⁶;P=0.001). However, mechanical disruption using hydrodynamic CAZSdecreased the S. aureus CFU count by 3.9 log units (5.11×10⁸ to6.37×10⁴; P=0.001) and the P. aeruginosa CFU count by 5.2 log units(1.69×10⁹ to 1.04×10⁴; P=0.001).

Confocal scanning laser microscopy (CSLM) was performed on three slides(for each treatment and bacteria species) not subjected to plate countsto allow imaging of the biofilm architecture in control and treatedsamples. The slides were stained for CSLM using a BACLIGHT™ Live/Deadkit (Molecular Probes, Invitrogen, Carlsbad, Calif.) containing twonucleic acid stains (SYTO 9, which detects living cells by fluorescinggreen, and propidium iodide, which detects dead cells by fluorescingred). After staining, the slides were examined using CSLM at a 630×magnification using a LEICA™ SP2 acoustic-optical beam splitter with a2-photon MAI TAI™ attachment (Leica Microsystems, Bannockburn, Ill.) andfluorescence excitation and detection in both the green and red spectra.Each slide area was divided into 10 equally sized segments. Amicroscopic field was selected at random from each segment, and imageswere obtained at 1-μm intervals from the top of the biofilm to thesubstrate, thereby creating an image stack for each location. The CSLManalysis revealed that a thick biofilm carpeted the Control slides.Hydrodynamic treatment with saline and static treatment with CAZSdecreased the amount of biofilm coverage markedly and reduced theorganization of the remaining biofilm. Hydrodynamic treatment with CAZSproduced a greater reduction both in biofilm coverage and in the amountof order in the biofilm community. The results corresponded generally tothe plate count assessments with respect to the relative reductions inthe amount of biofilm achieved with each treatment.

Of the three treatments investigated, power irrigation using CAZS and apressurized jet lavage was the most effective in disrupting thebacterial biofilms. Power irrigation using saline had appreciablebiofilm-reducing effects. However, the presence of a surfactant andcitric acid in the irrigation solution significantly enhanced thereduction in CFU count in both S. aureus and P. aeruginosa biofilms.Large, statistically significant reductions occurred, with the meandecreases in bacterial plate counts being 3.9 and 5.2 log (a reductionof 10,000 to 100,000 times), respectively, for S. aureus and P.aeruginosa biofilms. A decrease of this magnitude in vitro indicatesthat an appropriate in vivo treatment in the nasal or sinus cavitiesshould effectively disrupt bacterial biofilms found there. Any remaininglow level of persistent bacterial infection might be dealt with by hostdefenses or a topically or orally administered antimicrobial agent, andby application of a sealant as described above.

EXAMPLE 2

Experimental work conducted using S aureus and P aeruginosa culturesgrown on TSA solid medium (viz., cultures made without use of HA-coatedglass slides and the DFR and less likely to include a durable biofilm)indicates that a solvating system containing the surfactant but no metalion sequestering agent may be less effective as a biofilm disruptor thana solvating system which also contains the metal ion sequestering agent.However, either solvating system may be a more effective biofilmdisrupter than saline solution.

EXAMPLE 3

The CAZS solvating system employed in Example 1 was modified byreplacing some of the water with gallium nitrate so that the modifiedsystem contained 25% gallium nitrate. A Control solution containing 25%gallium nitrate in deionized water was also prepared. When evaluatedusing the static treatment technique of Example 1, administration of thegallium nitrate Control solution resulted in a 3.4 log reduction(average of 4 runs) in the number of S. aureus CFUs and a 4.1 logreduction (average of 3 runs) in the number of P. aeruginosa CFUs.Static administration of the solution containing CAZS and galliumnitrate resulted in a 5.2 log reduction (average of 2 runs) in thenumber of S. aureus CFUs and a 5.5 log reduction (average of 2 runs) inthe number of P. aeruginosa CFUs.

Although specific embodiments have been illustrated and described hereinfor purposes of description of the preferred embodiments, it will beappreciated by those of ordinary skill in the art that a wide variety ofalternate or equivalent implementations calculated to achieve the samepurposes may be substituted for the specific embodiments shown anddescribed without departing from the scope of the present invention.This application is intended to cover any adaptations or variations ofthe preferred embodiments discussed herein. Therefore, it is manifestlyintended that this invention be limited only by the claims and theequivalents thereof.

1. A method for treating rhinosinusitis and other bacterial sinusconditions, which method comprises: a) applying an aqueous solvatingsystem comprising a metal ion sequestering agent and a surfactant to atreatment site comprising a bacterial biofilm comprising anextracellular polysaccharide matrix attached or adhered to a surfacewithin a nasal or sinus cavity, b) detaching, removing or otherwisedisrupting at least a part of the biofilm by solvating the extracellularpolysaccharide matrix so as to provide greater than a 1-log orderreduction in one or more of Staphylococcus aureus, Pseudomonasaeruginosa, S. pneumonia, Haemophilus influenzae or Moraxellacatarrhalis bacteria, and then c) applying to the treatment site aprotective layer of a polymeric film-forming sealant.
 2. A methodaccording to claim 1 wherein the treatment site is in a nasal cavity. 3.A method according to claim 1 wherein the treatment site is in a sinuscavity.
 4. A method according to claim 1 comprising applying thesolvating system by spraying, lavage, misting, mopping, wicking ordripping and further comprising removing the solvating system from thetreatment site by flushing, rinsing, draining or absorption afterapplying the solvating system and before applying the sealant.
 5. Amethod according to claim 1 comprising applying the sealant by spraying,lavage, misting, mopping, wicking or dripping.
 6. A method according toclaim 1 comprising applying the sealant as a conformal coating.
 7. Amethod according to claim 1 wherein the surfactant comprises a cationicsurfactant.
 8. A method according to claim 1 wherein the surfactantcomprises a zwitterionic surfactant.
 9. A method according to claim 1wherein the surfactant is at least 0.2% of the solvating system.
 10. Amethod according to claim 1 wherein the surfactant is about 0.3% toabout 30% of the solvating system.
 11. A method according to claim 1wherein the surfactant is about 0.5% to about 25% of the solvatingsystem.
 12. A method according to claim 1 wherein the metal ionsequestering agent comprises a sequestering agent for sodium, calcium oriron.
 13. A method according to claim 1 wherein the metal ionsequestering agent comprises citric acid.
 14. A method according toclaim 1 wherein the metal ion sequestering agent is present at aconcentration of about 0.01 to about 0.5 M.
 15. A method according toclaim 1 wherein the solvating system has a pH of about 5 to about 8.5.16. A method according to claim 15 wherein the solvating system furthercomprises a buffer.
 17. A method according to claim 1 wherein thesolvating system further comprises an antimicrobial agent.
 18. A methodaccording to claim 1 wherein the sealant is viscoelastic.
 19. A methodaccording to claim 1 wherein the sealant hardens after application. 20.A method according to claim 1 wherein the sealant comprises apolysaccharide.
 21. A method according to claim 20 wherein the sealantcomprises cellulose, chitin, chitosan, dextran, glycogen,glycosaminoglycan, gum, pectin, starch, or a derivative thereof.
 22. Amethod according to claim 1 wherein the sealant comprises hyaluronan.23. A method according to claim 1 wherein the sealant comprisescarboxymethyl cellulose.
 24. A method according to claim 1 wherein thesealant comprises a lipid or polypeptide.
 25. A method according toclaim 1 wherein the solvating system or sealant further comprises anantimicrobial agent.
 26. A method according to claim 25 wherein theantimicrobial agent comprises gallium acetoacetonate, gallium bromide,gallium chloride, gallium fluoride, gallium iodide, gallium maltolate,gallium nitrate, gallium nitride, gallium percolate, gallium phosphite,gallium sulfate or mixture thereof.
 27. A method according to claim 1further comprising applying an antimicrobial agent after application ofthe solvating system and before application of the sealant.
 28. A methodaccording to claim 1 wherein the same steps performed in vitro willcause greater than a 1-log order reduction in a population ofStaphylococcus aureus.
 29. A method according to claim 1 wherein thesame steps performed in vitro will cause greater than a 2-log orderreduction in a population of one or more of Staphylococcus aureus,Pseudomonas aeruginosa, S. pneumonia, Haemophilus influenzae orMoraxella catarrhalis bacteria.
 30. A method according to claim 1wherein the same steps performed in vitro will cause greater than a3-log order reduction in a population of one or more of Staphylococcusaureus, Pseudomonas aeruginosa, S. pneumonia, Haemophilus influenzae orMoraxella catarrhalis bacteria.
 31. A method according to claim 1wherein the sealant further comprises an anti-fungal agent,antihistamine, steroidal or non-steroidal anti-inflammatory agent, anti-parasitic agent, antiviral agent, chemotherapeutic/antineoplastic agent,decongestant or mucolytic.